Basic Information
| Provider Information | |||||||||
| NPI: | 1497341457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDERO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MS, TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45747 LAKEVIEW CT APT 12105 | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483773846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806782842 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 N MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481032827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346693610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2020 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6362009079 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.